Overdiagnosis of Adult ADHD Is Exacerbating the Stimulant Shortage

ABSTRACT

Attention-deficit/hyperactivity disorder (ADHD) is a neurobiological disorder that, when accurately diagnosed, requires treatment to ensure patient safety and overall outcomes. The ongoing shortage of stimulant medications for ADHD treatment is exacerbated by a predictable funnel in health care from patient concerns to medication prescriptions. Widespread online misinformation about ADHD and stimulant medication leads patients to question whether they have ADHD. They share their concerns with providers, prompting an evaluation. Because of constraints that limit comprehensive neuropsychological assessments, providers typically rely on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for ADHD, often resulting in patients meeting the criteria and receiving a diagnosis—even when they do not actually have ADHD. This occurs because the DSM-5 criteria do not accurately represent the condition. Providers then prescribe stimulants, which are Schedule II medications regulated by the Drug Enforcement Administration. Despite efforts to increase production, the imbalance between supply and demand continues to drive the shortage. Now is a critical time to reassess the ADHD diagnosis and implement stronger guidelines and awareness.

Am J Manag Care. 2025;31(Spec. No. 3):SP145-SP149. https://doi.org/10.37765/ajmc.2025.89708

Attention-deficit/hyperactivity disorder (ADHD) diagnoses have reached an all-time high,1 and the stimulant medication shortage continues to be a public health crisis.1-3 Despite this, few guidelines exist regarding who is qualified to diagnose adult ADHD or how to diagnose it properly. Although many providers lack confidence in their ability to assess ADHD in patients,4 others promote their alleged qualifications online, regardless of their level of training.5 Governing bodies are working to increase stimulant medication production, and patients are often forced to switch from one stimulant medication to another.1,6,7 To mitigate the impact of the stimulant shortage on patients with ADHD, concrete, better guidelines are necessary for evaluating ADHD in adulthood.

The internet is saturated with information that romanticizes stimulant medication, portraying it as a means to “enhance focus and boost success.”8 However, this does not accurately represent how stimulant medication functions as a treatment. Serious neurocognitive deficits underlie ADHD, and stimulant medication enables individuals to safely complete everyday tasks, such as driving, by normalizing brain regions associated with attention and reward, but it does not inherently improve cognition.9 ADHD is associated with a 2.77-fold increased risk of developing dementia,10 but there is no increased risk for individuals who have used stimulants long-term. ADHD is also associated with early mortality, with people with the disorder dying an average of 10 years earlier than those without ADHD due to reasons that are preventable with consistent treatment.11 These examples highlight the importance of debunking the myth that stimulants act as cognitive enhancers and shifting the perception toward recognizing them as medically necessary.2,9-12 At this point, ADHD is a generally well-known mental health diagnosis,13 but that does not mean it is well understood. Media outlets are allowing predatory advertisements that oversimplify the ADHD diagnosis.14 When individuals search for attentional difficulties or mention them aloud, algorithms track this behavior and deliver ads that encourage viewers to get tested for ADHD and initiate stimulant use.14,15 This advancement in technology, along with an often inaccurate portrayal of ADHD in popular media,10,14,15 fosters unrealistic perceptions of adult ADHD and increases the desirability of stimulant medications.

Increased Production

Patients and families desperately seek answers as to why the stimulant medication shortage has not been resolved.2,3,6,16 Given that stimulants are classified as Schedule II medications, the Drug Enforcement Administration (DEA) controls their supply and has faced criticism for the shortage and its impacts,17 with some observers claiming that restrictions on production quantities prevented manufacturers from producing enough medication.17 The DEA refuted these claims, increased lisdexamfetamine (Vyvanse) and methylphenidate (Concerta) production in 2024,18 and allowed controlled substances to be transferred between pharmacy chains without requiring a new prescription from a doctor.19

Medication Has Become More Accessible

Other organizations are also working to mitigate the impacts of the stimulant shortage. For example, in 2024, UnitedHealthcare temporarily allowed patients to receive brand-name Vyvanse without going through step therapy or prior approval.20 Because of its higher price, Vyvanse is typically not considered a “step 1” medication. In a situation without a stimulant shortage, a new patient diagnosed with ADHD typically would first be required to try generic amphetamine salts (Adderall) or another less-expensive stimulant before filling a Vyvanse prescription. Thus, Vyvanse was made more accessible to patients with newly diagnosed ADHD and those whose stimulants were unavailable due to the shortage. With these efforts from governing bodies to end the shortage, Adderall and Vyvanse have been removed from the FDA shortage list, for now.3

Overdiagnosis of ADHD

ADHD diagnoses continue to grow rapidly7,12,13 and stimulant prescriptions have nearly doubled in the past decade, rising by more than 10% in the past few years.7,13 There is only so much pharmaceutical companies can do when demand severely outweighs supply. The overdiagnosis of ADHD may be the main reason for the shortage.12,13,17 In 2023, Jeffrey A. Lieberman, MD, a past president of the American Psychiatric Association, told Psychiatric Times®, “I think the problem is not so much that we have a shortage of medication, but rather an overdiagnosis of the condition. There is no way that ADHD, as reflected by prescriptions for psychostimulants, can be more frequent than it is in Western Europe and other parts of the world. The question is: How and why is this happening?”21

It’s Not the Clinicians’ Fault

Many clinicians who diagnose patients with ADHD lack the adequate training to assess and diagnose patients properly.4,22 However, this is not their fault, as properly assessing ADHD requires a comprehensive evaluation of executive functioning deficits, which are not included in the self-report form within the diagnostic criteria of the most recent revision of Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).12,13,23 Regardless, only 8% of primary care providers indicated being extremely confident in their ability to diagnose and treat patients with ADHD,4,22 and many have requested extra training.4,22 Prescribing clinicians often have limited training in diagnostic assessments and must rely on available resources, primarily DSM-5’s diagnostic criteria, to diagnose the condition.22,23 This is problematic because using the criteria for diagnosing ADHD is said to “put providers at risk of inappropriately diagnosing.”6,12,16

Evidence of DSM-5’s Flaws When Used to Diagnose ADHD

Although DSM-5’s criteria can be used to identify people who do have ADHD, they cannot accurately be used to rule out people who don’t have ADHD.24,25 Supporting this notion, high-quality studies have tested individuals who do not have ADHD (including neurotypical people and people with other mental health conditions) and found that many endorse moderate to high levels of ADHD symptoms, thus meeting the criteria for ADHD as outlined in DSM-5.12,24-26 In other words, many people meet DSM-5’s diagnostic criteria for ADHD, even though they do not have ADHD.26 For this reason, we can’t blame clinicians for their lack of understanding of ADHD when DSM-5’s diagnostic criteria omit the core deficits central to it. Specifically, the current criteria describe the effects of executive functioning deficits central to ADHD rather than the deficits themselves.12 Given the neurobiological basis of ADHD, self-report assessments of inattention alone are insufficient to warrant a diagnosis.27 A high-quality assessment for an ADHD diagnosis involves at least 2 hours of extensive neuropsychological testing,28 but we recognize that many providers find this process unrealistic because of time and training restraints (Figure).

Current Expert Consensus for Diagnosing Adult ADHD

DSM-5 serves as a de facto position statement on the diagnosis of ADHD. The American Psychiatric Association29 and the CDC1 provide DSM-5’s criteria in an easy-to-follow format to define and diagnose adult ADHD. The American Psychological Association also advises following DSM-5 while emphasizing the importance of verifying symptom onset before age 12 and considering comorbidities.30 Yet, these guidelines remain insufficient, given that DSM-5 does not accurately represent ADHD.12

Our Solution

To improve the accuracy of ADHD diagnoses and alleviate the impacts of the shortage and its consequences, the authors propose that diagnosing clinicians should, at the very least, conduct a thorough evaluation with an understanding of 2 key facts: (1) executive function and emotion regulation deficits are core features of ADHD,12,13,26,27 and (2) many people in the general population exhibit moderate to high ADHD symptoms included in DSM-5’s criteria, but that does not mean they have ADHD (which explains the high prevalence of false positives, also known as poor specificity in psychological statistics for criteria and scale development).24-26 We propose following the guidelines of experts such as Russell A. Barkley, PhD (sometimes called the “Father of ADHD”), which emphasize multiple executive functioning and emotion regulation deficits as necessary symptoms for an accurate ADHD diagnosis.12

Discussion

This article aims to raise awareness about the stimulant shortage and calls on providers to conduct accurate assessments before diagnosing ADHD.5,6,16 The authors, along with several ADHD experts,12,13 believe that the stimulant shortage is likely, in part, driven by an inaccurate representation of ADHD by DSM-5.13,25-27 Rather than placing restrictions on patients, we believe the focus should shift to providers. They should be encouraged not to diagnose ADHD solely on a brief assessment of symptoms outlined by DSM-5. This would be a small step toward addressing the issue of overdiagnosis of ADHD that is exacerbating the stimulant shortage.

Future Directions

ADHD experts suggest adjusting the adult ADHD DSM-5 criteria to reflect the core executive dysfunction deficits,”12,13 and we agree. Future revisions of DSM-5’s criteria should involve clinical psychologists and neuropsychologists specializing in diagnosing and assessing adult ADHD and psychometric scale development to help develop the criteria for adult ADHD. Including a variety of practitioners and patient advocacy groups who bring personal experience would also be beneficial. The current edition of the DSM-5 does not align with best-practice ADHD assessments,4,28 as these assessments involve neuropsychological testing. In neuropsychological evaluations, self-reported symptoms play a minor role, and clinicians focus on measuring a person’s executive functioning and emotion regulation abilities. Therefore, future DSM criteria should reflect the executive functioning and emotion regulation deficits associated with ADHD to enable more accurate assessment in adults. Additionally, if practitioners lack knowledge of key statistics and psychometric standards—such as sensitivity (the ability to accurately identify people who meet the criteria for a condition) and specificity (the ability to accurately exclude those who do not meet criteria)—they may struggle to apply diagnostic criteria that omit what neuropsychological evaluations can provide. This omission highlights the importance of including the central deficits of ADHD in future DSM criteria development. Overdiagnosis leads to serious consequences, such as the stimulant shortage. Therefore, the authors and their colleagues are developing a procedural guide for assessing adult ADHD that aligns with best practices. This guide will help clinicians without sufficient ADHD assessment training to more accurately assess adult ADHD.

Author Affiliations: Department of Psychological Sciences, Kent State University (SMA, JWH), Kent, OH; Giant Eagle Pharmacy (BLT), Akron, OH.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SMA); drafting of the original manuscript (SMA); contributing important intellectual content and editing the manuscript (SMA, BLT, JWH); and final approval (SMA, BLT, JWH).

Send Correspondence to: Salayna M. Abdallah, MA, BS, Kent State University, 3502 Ivanhoe Dr, Kent, OH 44240. Email: salaynaabdallah@gmail.com.

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